Tailoring off-the-shelf global evidence with local implementation research can boost action on overweight and obesity
Authors: Angela M Jackson-Morris, Jaime Miranda, Rachel Nugent
Journal: The Lancet Global Health (2023)

Overweight and obesity prevalence among children and adolescents in low-income and middle-income countries (LMICs) rose steeply from 2·5% to 17·3% between 1975 and 2016.1WHOOverweight prevalence among children under 5 years of age (% weight-for-height >+2 SD).https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-jme-country-children-aged-5-years-overweight-(-weight-for-height-2-sd)Date: 2023Date accessed: January 10, 2023Google Scholar, 2Okunogbe A Nugent R Spencer G Ralston J Wilding J Economic impacts of overweight and obesity: current and future estimates for eight countries.BMJ Glob Health. 2021; 6e006351Crossref PubMed Scopus (65) Google Scholar By 2020, 39 million children younger than 5 years and 341·6 million children and adolescents aged 5–19 years were affected. This situation is concerning in terms of the current and future burden of non-communicable diseases in LMICs, because children and adolescents who are overweight or living with obesity are more likely to have high blood pressure, high cholesterol concentrations, type 2 diabetes, asthma, joint problems, gallstones, anxiety, and depression.3Sahoo K Sahoo B Choudhury AK Sofi NY Kumar R Bhadoria AS Childhood obesity: causes and consequences.J Family Med Prim Care. 2015; 4: 187-192Crossref PubMed Google Scholar Addressing the issue of children and adolescents being overweight or living with obesity has the potential to be transformative for their health in adulthood and will slow the steeply rising trajectories of associated non-communicable diseases. Implementation research can be instrumental to supplement globally recommended interventions with contextually relevant information for different countries. Various evaluated policies and programmes have shown effectiveness for children and adolescents. In 2022, WHO revised its earlier recommendations published in 2017, proposing an expanded set of population level strategies to address physical activity and unhealthy eating—two major risk factors for overweight and obesity.4WHODraft—updated appendix 3 of the WHO global NCD action plan 2013–2030.https://cdn.who.int/media/docs/default-source/ncds/mnd/2022_discussion_paper_final.pdf?sfvrsn=78343686_7Date: June 28, 2022Date accessed: November 22, 2022Google Scholar Although the range and number of implemented policies in LMICs have increased since WHO issued recommendations in 2017, gaps remain in LMIC research capacity for obesity prevention and implementation research, alongside weak investments in evaluating interventions.5Roberto CA Swinburn B Hawkes C et al.Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.Lancet. 2015; 385: 2400-2409Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar Global evidence provides a solid foundation for reducing overweight and obesity, but it cannot guarantee success. Tailoring an intervention to context so that it reflects specific circumstances and capacities is a core implementation research tenet. Policy makers and stakeholders often prefer evidence related to their unique national situation, and policy makers in LMICs do not have the confidence that global recommendations can apply to the context in their countries. This problem applies to non-communicable diseases more widely and might be a limiting factor regarding the adoption and operationalisation of WHO's global recommendations to tackle overweight and obesity. At present, many countries rely predominantly on informational or educational initiatives that have been consistently found to be ineffective; yet, these initiatives could be regarded as politically uncontroversial and straightforward to implement.6Bellew W Bauman A Kite J et al.Obesity prevention in children and young people: what policy actions are needed?.Public Health Res Pract. 2019; 292911902Crossref PubMed Scopus (18) Google Scholar Therefore, although in recent years several LMICs have pioneered bolder national-level policies and produced evidence of impact, a far larger number have not. Implementation research across wide-ranging issues and contexts indicates that cost-effectiveness, readiness, and intervention acceptability are factors that can directly influence intervention adoption and implementation.7Langer L Tripney J Gough D The science of using science: researching the use of research evidence in decision-making.https://discovery.ucl.ac.uk/id/eprint/1493171/Date: April, 2016Date accessed: December 15, 2022Google Scholar, 8Panisset U Koehlmoos TP Alkhatib AH et al.Implementation research evidence uptake and use for policy-making.Health Res Policy Syst. 2012; 10: 20Crossref PubMed Scopus (56) Google Scholar Our work in several countries suggests that generating tailored evidence on the suitability of implementing interventions that have been found to be effective elsewhere could help countries to more effectively take action on overweight and obesity in children and adolescents. For example, in formative research in low-income communities in Kuala Lumpur, Malaysia, which was carried out to identify community-preferred interventions to address obesity, elected community leaders indicated that acceptability to local people was a prerequisite to gain support for these initiatives. The project met this need via a discrete choice experiment survey, which enabled community members to select the globally effective interventions most pertinent to their community.9Kocher E Wood D Lim S-C et al.Community priorities for obesity prevention among low-income adults in Kuala Lumpur: a discrete choice experiment.Health Promot Int. 2022; 37daac156Crossref PubMed Scopus (1) Google Scholar The interventions that resonated the most were those that improved the affordability of fruit and vegetables; incentivised healthier purchases with reward incentives; and reduced the salt, sugar, and oil content in food and beverages. The community's priorities were then reflected in the implemented interventions.9Kocher E Wood D Lim S-C et al.Community priorities for obesity prevention among low-income adults in Kuala Lumpur: a discrete choice experiment.Health Promot Int. 2022; 37daac156Crossref PubMed Scopus (1) Google Scholar UNICEF has found that LMIC stakeholders believed that a scarcity of economic evidence contributed to under-recognition and under-resourcing of research on overweight and obesity in children and adolescents. In response, UNICEF collaborated with stakeholders and researchers to develop a methodology and prepare investment cases in several countries (eg, Mexico10Brero M, Jackson-Morris AM, Spencer GJ, et al. Investment case for the prevention and reduction of childhood and adolescent overweight and obesity in Mexico. Obes Rev (in press).Google Scholar) to provide a focus for government and stakeholder discussions. Research has shown prevalent misapprehensions regarding strategies to address obesity,5Roberto CA Swinburn B Hawkes C et al.Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.Lancet. 2015; 385: 2400-2409Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar under-developed research capacity in many LMIC research communities (ie, in academia and civil society), and a consequently weak contextual understanding of the issue (with policy makers perceiving globally recommended interventions as not suitable for their context), even in regions that have acknowledged the scale of the problem. Although readiness analyses on various health issues have been widely undertaken to assess the capacities and willingness required to effectively implement global health policies or programmes, these types of assessments on overweight and obesity in LMICs are rare. Readiness analyses could provide crucial information on feasibility, gaps, and capacity development needs, and they could tangibly answer concerns about whether an intervention would work in a specific country. The rate of increase in overweight and obesity prevalence among children and adolescents in LMICs requires effective local action to avert the increase in non-communicable diseases and economic losses that will otherwise follow. Supporting stakeholders and building specific research capacity in LMICs to tailor off-the-shelf global evidence with implementation research to establish the most cost-effective, acceptable, and feasible strategies, as well as guiding how these strategies should be implemented, can inform and boost countries' actions. We declare no competing interests.